W/M3r (£  ^J
WITH THE WRITER'S COMPLIMENTS.
            A CASE OF




COMPLETE INVERSION OF THE UTERUS,
WITH REMARKS UPON
THE MODERN TREATMENT OF CHRONIC INVERSION.
CLIFTON E. WING, M.D., Boston.
( o
 
 
A CASE OF COMPLETE  INVERSION OF THE UTEftFS.*
Reposition  14 Months after the Confinement by means of Continued Mode-
      rate Pressure, without the Aid of Ax.esthesia.  Remarks upon
              the Modern Treatment of Chronic Inversion.
By CLIFTON E. WING, M. D., Boston.
   The  history of the case, which was seen in  consultation  with Dr.
 J. R.  Bronson, of Attleboro', is as follows:—
   The patient was a native of Massachusetts, 36 years old.  Menstruation,
 which began when she was 13, was regular until her present trouble.  Usual
 time of flow 5 days. Amount normal.  No dysmenorrhoea.  No leucorrhcea.
 She was first married when 19, and to her second husband when 33.  Had
 four children by her first husband, all her confinements passing off well and
 presenting nothing noteworthy.  Never any miscarriages.  Was hearty and
 able to  be about her household duties up to the time of her fifth confinement
 (14  months before seen), which began with a discharge of waters.  She was
 attended by an "irregular."  Was in labor 40hours from the time the waters
 broke, when she was delivered with instruments, a second physician being
 in consultation.  Flowed "awfully " at the time.  I did not learn that there
 was any trouble in the delivery of the afterbirth.  She had  a  slight  bloody
 discharge for two weeks, but "nothing more than natural." Stayed  in bed
 5 weeks. Duriug this time, i. e. until she was up on her feet, her urine drib-
 bled away continuously, and she states  that she was very much bloated ;
 her  "stomach was very large."  Her medical attendant did not use  a cath-
 eter, nor propose it.  When she got up (at the expiration of the 5 weeks),
 she  found that after being on her feet a short time uterine flowing would set
 in, ceasing when she kept her bed a few days, only to reappear when she
 again  left it.  Two months after confinement she had a severe haemorrhage,
 flowing  " nearly to death."  Has flowed three-fourths of the time since.  She
 states  that  the physician when  called told her each time  that the flowing
 was probably the return of menstruation.  Finally, as he did not come when,
 sent for, Dr. Bronson was called in—diagnosed  an inverted uterus, and asked,
 me  to see the case with him.
  The patient, a large, rather heavy woman, was found dressed and lying
 upon a lounge.  She was exceedingly anaemic, as much so as any patient
 with chlorosis.  Pulse feeble, under the excitement of the visit running up to
 over 120  in the minute.  Appetite good.   Bowels regulated  by medicine.
 Has not  flowed for the past few days.  Has no special pain, but complains of
 great weakness and complete exhaustion on attempting to do the least thing.
  On introducing with  care a Sims speculum,  the  vagina  was found filled
 with a pretty firm, red, fleshy tumor, having a tendency to  bleed, the blood
 oozing from the surface in drops wherever it was touched.   As far  as could
 be felt, its base was large and not pediculated, and there  seemed but little
 doubt as to the character of the case.  On account of the free  bleeding, the
 examination was carried no further at the time, but the patient was advised
 to come to Boston for treatment, which she did some weeks later.
  When  she arrived in  the city, Feb.  13,  187(J,  she was flowing freely, and
stated that from the fact that she lost much blood just four weeks before, she
was  disposed to think it might be her time of mens is.
  She was sent to bed, the foot of the bed to be elevated as much as she could
bear, and after four days in  this position, the flowing having meantime ceased,
• A paper read before the Suffolk Medical Society, Nov. 29, 1879. 
2
was put upon full doses of Tr. Forri Chlor., and ordered  copious hot-water
vaginal injections several times daily.  These were continued 5 'days, when
on second examination, the tumor was found much less tender, less congested,
in fact now rather pale and showing very little tendency to bleed when hand-
led.   That the tumor was the inverted uterus was sufficiently plain without
resorting to the various methods of verifying the diagnosis, such as rectal
touch, sound in the bladder, etc.  etc., which are  laid  down in the books.
These would have caused pain unless an anaesthetic had  been used, and were
not adjudged necessary in view of  the method  of treatment  I was about to
employ—a method which in itself  is an excellent means of  diagnosis.  The
inversion was complete ; in fact, anteriorly, it even  involved the  upper part
of the vagina.
  I had previously determined to treat the case by continued pressure ap-
plied to the inverted fundus.   Thinking I might find the  " stem and cup "
figured by Barnes, or some stem supporter which I could make use of, I  ap-
plied at the various instrument dealers, but did not succeed in finding anything
which suited  my purpose, and finally employed a  common old-fashioned
wooden stethoscope, as a  stem to  go  into the  vagina and  press upon  the
uterus, tying strong sheet rubber over the open larger end (the  end applied
to the chest in auscultation), and thus  making a soft cushion  at that end.
The other end projected from the  vulva.  Pressure was obtained by using
two pieces of common elastic  tubing passed between  the thighs, where they
were tied by the middle to the outside end of the stethoscope, the ends being
drawn tight and attached in front and behind to a waist  belt. I  found that
by regulating the tension of these elastic bands, not  only could  the  amount
of pressure be easily controlled, but the direction of the force be perfectly
managed.   In these respects nothing better could be  wished  for ; but under
the pressure the sheet rubber  which I had stretched  across the open end  of
the stethoscope became so much depressed that the sharp  rim of the latter
was going to cut into the uterine tissue.  I therefore  substituted for the
stethoscope a piece of wood of much the same shape (for after the practical
trial I did not see how  this could be improved), but solid, the upper end (i. e.
the end applied to the tumor)  being a little concave that  it  might not readily
slip to one side, and for the same reason being made large enough to fill the
calibre of the vagina.   The evening of the second day there was evidently
some gain.   A cavity of the neck now existed all around  the inverted fundus,
and it was of sufficient depth to receive the latter enough to prevent  it from
slipping about in the vagina, i. e. it held it so well in  position that pressure
must  act in the right direction.  Therefore as the large end  of the first  re-
positor was rather uncomfortable for the patient from distending somewhat
the vagina, I made use of a second  one, the upper end  of which  was  of less
diameter and  could be employed to follow  the fundus  up inside the cervix.
The upper part of this second one was also made of the same diameter for
several inches from the upper end, that the cervix  having been  passed the
latter should not contract and cause trouble in the removal of the instrument,
as has several times been the case where " a cup and stem " have been used.
The evening of the third day the  patient felt  a little restless.  The pulse,
which was at 96 when the process began, ran  up to 108.  She complained  of
being tired.   To insure her a  quiet night (she  had had good nights so far,
sleeping well), I gave her a £ gr. dose of morphine, which was all the medi-
cine, with the exception of the Iron tonic, which she received.  She slept well,
but was waked up in the middle of  the night by feeling " something jump in-
side," as she expressed it, and she immediately found that the pressure from
the apparatus had ceased.
  When seen in the morning, she was  feeling nicely ; had  no pain, and her
pulse was again 96.   On examination, 1 found the uterus replaced,  and the
end of the instrument extending up into its cavity.
  I had not anticipated so speedy a result,  and  not being supplied with my
proper instruments, in order to assure myself before leaving the patient that
there was no partial inversion still left, 1 improvised a bougie by  cutting off"
the end of a broom handle  and smoothing it with sand-paper which happened
to be at hand.   This I passed without difficulty into the canal of the uterus,
to the depth of 31 inches, and  thus proved that  the resposition was complete, 
3
  The patient was kept in bed for a few days, and the hot water injections
continued.  When she got up, five days after the return of the organ to its
place, she said that she Celt perfectly well.  A dragging sensation in the left
side, from which she had suffered much, was gone, and she was able to stand
and walk in  a  perfectly  erect position, which she had not done since sick.
She returned home a week later, and menstruation, which occurred soon after
her return, was normal  in  every way.  She regained her strength rapidly,
and Dr. Bronson lias recently informed me that she  continues  well and is
again pregnant (at about the fifth month).
  During the treatment she took no anaesthetic, and no anodyne except the
i gr. of morphine referred to ; and according to her own statement, suffered
no more pain than she had frequently had in the same length of time during
her illness.  She ate heartily and took her Iron tonic regularly.
  There was a free discharge of mucus from the inverted mucous membrane,
but scarce a trace of suppuration.   The  fundus bore the pressure without
damage.  Experience has shown that the inverted organ is much more tolerant
of continued pressure  than  would naturally be supposed.  The instrument
was removed and cleansed daily, and before it was replaced the parts thor-
oughly washed out with  a disinfectant solution.  This diminished the risks of
septicaemia, and also afforded an opportunity  of watching the condition of
the parts where the instrument pressed.
  The effect of hot water injection, employed after the method indroduced by
Dr. Emmet, in reducing the congestion and sensibility of the parts, was very
satisfactory.
   The value of continued gentle pressure in the treatment  of  inversio
 uteri  seems  to have been but little appreciated by the profession at
 largo,  although its merits  have been sufficiently proven  by  the  suc-
 cessful cases which have been from time to time reported, particularly
 in Great Britain*.
   The main difficulty in the return  of the uterus to its proper position
 lies in the fact that that portion of the uterus which is  not  inverted—
 or, in case of complete inversion,  the  cervix—contracts  behind  the
 inverted portion, and  must be dilated in one way or  another before
 the inversion can  be returned.
   It  is a well known physiological fact that the  strongest  muscle,
 which would be powerful  enough to resist great force applied for a
 comparatively  short  time,  can  yet  be completely  overcome and
 thoroughly stretched  by the  continued application of very little force.
 Now the whole uterus, and  therefore, of course, that portion of it
 which in the given cases constitutes the impediment to reposition, is
 to all intents and  purposes  a muscle, a  muscle  strong  enough  to
 successfully resist in  many*cases  the force applied in  taxis—a force
 which can be applied  but a little  while at a time, and which more-
 over  is often not very great  since the hand of  the operator works at
 a great  disadvantage  and soon  tires—but  which cannot  withstand
 the action of long continued pressure upon the  fundus,  even when  the
 amount of pressure is but  slight.
   There are two reasons which  may partly explain  why  continued
 pressure has not been more  highly  esteemed in these cases.    In  the

  * In the Boston Mcdiealand Surgical Journal of Jan. 13, 1876, is an interesting and in-
structive report by Dr. Geo. G. Tarbell, of this city, of a case which occurred in his service
at the Massachusetts General Hospital. Continued gentle pressure proved successful after
other means had failed.  This was one of the earliest eases treated by this method. Dr. T.
had a second successful case not long afterward. 
4
 first place, it has probably been pretty generally supposed  that the
 inverted organ would not tolerate  pressure upon  its mucous mem-
 brane for any length of time.   This idea experience has proved to
 be fallacious, although we may of course  expect that certain cases
 may be the exceptions which prove the rule.   Secondly—where con-
 tinued pressure has been attempted, stupidly enough, in most cases
 an elastic bag introduced into the vagina, and then  distended  with
 water or air, has been employed.   The  bag being  in contact  with
 the vaginal walls over a much larger  surface  than it is  in  contact
 with the inverted uterus, in accordance  with well known laws much
 more  of its  power has  been expended in dilating the vagina and
 stretching the surrounding tissues than in elevating the uterine body.
 This very distention of the vagina, if the bag be forcibly distended,
 of itself often causes more pain than the patient can bear, as is well
 known  by many who have employed such bags as vaginal  tampons
 in cases of uterine  haemorrhage.   Where  success has followed  the
 use of the vaginal bag, in these cases, either the vagina and surround-
 ing tissues have been remarkably tolerant of distending force, or, as
 has undoubtedly  been  the usual case, the uterus has been replaced
 by remarkably little continued pressure exerted upon it.    It is evi-
 dent that a full and  fair trial of continued pressure cannot be made
 in this way.  Although the inefficiency of the elastic vaginal  bag has
 been repeatedly pointed  out and written about, it is still resorted to
 in such cases;  and where it has been found on trial that the patient
 could not bear its continued use, or that it did  not replace the uterus,
 the operators—often those who might be expected to know better—
 have  generally  concluded that  the uterus was  too sensitive  for
 continued pressure  treatment, or  that  pressure  faithfully tried had
 proved  a failure.   Often, too, the pelvic pains and tenderness, caused
 simply by the distension, have been  mistaken for the symptoms  of
 pelvic peritonitis.
   [There is a  noticeable want of clearness on the part  of  certain
 writers as to what constitutes <lelastic pressure" in these cases. 8ome
 of the text books, in treating of the methods of reduction,  use  the
 term " elastic pressure "  in a somewhat peculiar and, it would seem,
 in an improperly restricted sense.  For example : Dr. T. G. Thomas,
 in his work on The Diseases of Women, distinguishes the method of
 reposition by "pressure  by vaginal stem  and  cup  or bulb" from
 those by "elastic pressure combined with taxis" and "elastic pressure
 alone."   Certainly  the first method (by vaginal  stem etc.), as prac-
 tised by Barnes, Tait, Aveling and others, and employed in this case,
 stretched elastic bands furnishing the power, is a most practical way
 of employing  elastic pressure;   whereas  the  elastic vaginal bag,
 which the author apparently means when he says  " elastic pressure "
is, as  already stated, a decidedly inefficient agent.   Dr. Barnes, also
 often  uses the expression " elastic  pressure," when he  means  the
vaginal bag.   It is a loose use of terms likely toconfuse the reader.]
   It is rather strange that in one of the latest works upon Gynaecology
—the excellent book of Dr. Emmett, published in 1879—the author 
5
 in treating of inversion of the uterus, while he enters at length into
 the  various methods of applying taxis, including  his own, makes no
 mention of the use of continued pressure.  Dr. Emmet describes and
 illustrates by diagram a method which he has devised and practised,
 when he has partially replaced an inverted  uterus by taxis, carrying
 the fundus above the external os, but  has been unable at the one
 sitting to complete the reposition.  In such cases, he  has temporarily
 closed  in  the cervix  below the  now partially replaced  fundus, by
 means of wire sutures.   He writes, p.  431, " When, from any cause,
 the attempt at reduction has to  be abandoned for the time, an exten-
 sive amount of dilatation is thus preserved until the condition of the
 patient will admit of another  effort in  her behalf,    On  a  moment's
 reflection it will be evident that a persistent dilating force is at once
 established, without taxing the strength of the patient, which may of
 itself, in some cases, complete  the reduction unaided.  By stretching
 the cervix over the fundus, an  unyielding mass  within  the uterine
 canal, a force is exerted on the  outside  of  the organ to roll out the
 parts above, while at the same  time an upward  action  is at once
 established below the inversion by forcing the fundus as a wedge  in
 the  direction  offering the least resistance.  Then any action of either
 the  longitudinal  or circular fibres  of  the uterus, or both  together,
 will aid in the reduction."
   It is true that in certain cases, after the cervix has been thus tem-
 porarily closed, uterine  contractions have completed the reduction.
 The case reported in  the  Boston  Medical and Surgical  Journal  of
 1879, p. 251, by  Dr. E. II. Stevens, of Cambridge,  is  an example.
 The patient  had pains resembling  labor pains, and afterward the
 uterus was found in its normal position;  but we cannot in  all cases
 count upon uterine action lending such  efficient aid.
   Dr. Emmet further writes,  " The power exerted " (i. e.  when the
 cervix is closed by sutures), "is exactly  that brought to  bear on the
 uterus when the  vagina has been  fully  distended  by an  air bag."
   One cannot but judge that the power brought to bear upon the uterus
 in closing  the cervix by this method, must be  less than that exerted
 upon that organ  by the vaginal bag even, for  otherwise  the sutures
 would  inevitably cut out in a  very short time.    While  in certain
 exceptional cases this procedure of temporarily  closing  the  cervix
 may prove exceedingly valuable, I believe that proper direct pressure
 upon the fundus will ordinarily  prove much more efficient and relia-
 ble, and it is certainly a simple method  of treatment.    The wedge
 action  exercised  by the inverted portion  as it  is pressed upward,
 spoken of  by  Dr. Emmet, will  by this means be  fully  developed,
 while  the pressure will, as Barnes says, " tend to press out the blood
 and serum from the body of the uterus, diminishing its bulk and ar-
 resting hasmorrhage."  At the  same time, the longitudinally stretched
 vaginal walls, in  resisting the  elevation  of  the uterus as  a whole,
 will, through their attachment  to the cervix uteri, exercise  a  really
 efficient force, tending to open  the "circle of resistance."   I suspect,
that if it is  tried in the future in such cases, the second attempt at taxis 
6
will rarely be necessary, as the operator will probably be agreeably
surprised  to find, on his next examination, that  the womb  has re-
sumed its  proper position.   Indeed, if the continued pressure method
is  tried in the first  place, there will not often be any necessity for
taxis  first or last.
   The procedure of permanently  closing in the cervix below a par-
tially reduced inversion, [leaving of course an opening for the escape
of menstrual and other secretions.]  as first proposed and practised by
Dr. Emmet, may  prove valuable where the  full reposition  is impossi-
ble, but that  an  inversion  is irreducible is a  condition  he  is " not
willing to acknowledge except under  very unusual  circumstances."
Dr. Emmet gives the  notes of a case where  he thus closed  in  the
cervix, when, as was thought, adhesions  prevented full reposition by
taxis.  As he gives the notes of another case where adhesions, which
at first prevented  reposition,  gave way  after temporarily closing
the cervix  by silver  wires, as above described,  it  is interesting to
think whether here proper continued  pressure  upon the fundus, with
its much greater  efficacy, might not have safely completed the repo-
sition.   Dr. Barnes  calls  attention  to  the  fact that oftentimes the
autopsy has failed to  reveal the adhesions which were diagnosticated
during the life of the patient, and that adhesions  are much rarer in
these cases than  would  naturally  be supposed.
   The method of treatment  by taxis is  eminently proper in  acute
cases of inversion—cases seen soon after the accident has happened,
and before the womb has firmly contracted.    Haemorrhage may be
so severe,'and other symptoms may  be so urgent, and  moreover repo-
sition with the hand is  often so  easy at this time, the uterine fibres
being relaxed, that it is the proper method to try;   but  in  chronic
cases  I  believe  the  treatment by continued  moderate  pressure is
much more rational and better  for the patient, although success, per-
haps, is not accompanied by such eclat.
   In  the  published  " Transactions  of  the  American International
 Congress" of 1876,  is an article  upon "Chronic Inversion of the
Uterus," by Prof. J. P. White,  of Buffalo, who has done as much as
any one to demonstrate the feasibility of reduction in such cases, and
operated  successfully upon very many  cases, one  of even  twenty-
two years' standing.  He writes, p. 876—"The uterus becomes as small
 and inflexible immediately upon the conclusion of involution,  which,
 according to the best authorities,  occurs  within  twelve  or at most
 sixteen weeks after delivery, as at  any subsequent period before the
 menopause.   Reduction, therefore,  at the expiration  of  twenty years
 is not more difficult than after  the  same number of weeks,  as far as
 the manipulation of the organ itself is concerned.  There is, however,
 an intervening period between the commencement and the conclusion
 of the process of involution, when the organ must in my opinion be
 handled  with more care.   While undergoing  this change, the uterus
 does not possess the firmness and elasticity of the unimpregnated organ,
 nor  the muscular flexibility and  toughness of that  at full period  of
 gestation.   Whilst in this transition state undergoing the process  of 
7
fatty degeneration, it is, I  apprehend, far more brittle  and liable  to
rupture than after the change is fully accomplished......
It will probably be found safer, in view of this friable condition of the
tissues after the commencement of involution, to wait for the completion
of this process, notwithstanding the increased difficulties of the opera-
tion occassioned by such delay."
  The force of this last sentence depends very much upon what method
is to be employed in the reduction.   Where  taxis  is  employed, no
doubt  it is true, and even Dupaul, employing forcible reduction  at
this stage, once penetrated a uterus  with  a wooden repositor; but
where only  moderate continued pressure, applied through a suitable
vaginal stem and  properly regulated,  is used, I should  not anticipate
trouble even  during the  stage  of involution.   Still,  unless urgent
symptoms were present, interference might be postponed until later.
   The method employed by Dr.  White,  of taxis combined with the
use of his  repositor (a vaginal  stem with a spiral spring at its ex-
ternal end, against which the operator  presses his body and thus keeps
up pressure  upon  the fundus during  the  manipulations), although a
step in the right direction, and  less likely to do harm than where the
force of the fingers alone is relied upon, is nevertheless a very different
procedure from the " continued moderate pressure " method. Dr. White
thinks it  is incorrect for Dr. Barnes to call his method  " a forcible
reduction." He points out the fact  that gynascologists of  the present
day do not hesitate to dilate the uterine canal  when necessary, and
asks, " why may we not pull open  the neck by means of the vagina,
in  the same  gentle manner as we could press it open when in a nor-
mal position ?" and says, " the vagina pulls  open  the os  with less
liability to laceration than the pressure of the  tent, the india rubber
bag, or any  other mechanical means can do."
   This may be perfectly true, but gynaecologists of the present day,  in
using  tents to dilate a firm non-pregnant cervix, do not expect full
 dilatation in the short time—at  most a very few  hours—in which Dr.
White at one sitting completes  his operation.   Indeed no better ex-
ample of the efficacy of " long continued moderate  pressure " could
 be desired, than is afforded by the action of a  sponge-tent.
   I think Dr. Barnes is in a  measure  right when he  speaks  of the
 method of " forcible reduction " as having been  confounded with that of
" gradual reduction by sustained pressure."  He writes further—" The
 principles of the two procedures are totally opposite.  One tries  to
 overcome resistance by sheer force applied rapidly, the  other by wear-
 ing out resistance  by gentle pressure  long sustained.   The first  is
 replete with danger, the second almost absolutely safe."
    While at the hands of one as experienced and able as  its inventor,
 White's method may be quite safe, when essayed by those less able, I can
 easily conceive that harm might be  done.  It moreover necessitates the
 use of anaesthesia, as do all methods of taxis ; is attended, as far as the
 patient is concerned, with all the horrors of a  surgical  operation; re-
 quires the presence of assistants, and is often accompanied with more
 or less shock, several patients having exhibited  tendency to collapse 
8
during its performance—whereas the "continued moderate pressure "
method requires scarce any skill in its application, does not ordinarily
necessitate anaesthesia or the presence of assistants, and is not  terri-
fying to  the patient; in fact,  is so simple a procedure  that  it hardly
deserves to be classed among surgical operations.*
   An interesting case is reported by Dr. J. Matthew Duncan, in  the
St. Bartholomew's Reports  for 1878 (vol. xiv.), in  which he treated
complete inversion by continued pressure, after removing a sloughing
fibroid which was attached to the inverted organ.   On the first attempt
continued pressure had to be abandoned for the time being, on account
of "abdominal pain, vomiting and general distress" which it caused.
On removal of the apparatus employed, the body of the  uterus  was
found " pressed up within the cervix."   (Here was an instance where
Emmet's method of temporarily closing the cervix might have proved
advantageous.)   A week later, a second attempt failed, from the in-
strument slipping off the fundus.  A week after this, on June 4th—two
weeks after the first attempt—continued pressure was applied for the
third time.  At the end of seventy-four hours " the patient felt a sud-
den and  severe pain in the hypogastrium," and said  she " felt the  in-
strument slip into her body."  The  pain was worse  after this.   She
felt faint, and  was sick twice.   She was given brandy and morphine.
Two days after this, "the instrument  was with some difficulty removed
from the uterus in whose cervix it was incarcerated."—July 2d, she
left the hospital, but three weeks afterward she died.   There was no
autopsy,  and no satisfactory account of the cause of death could be
obtained.  Still something may perhaps be learned from  the report
of the case.
   Another time, when a first attempt  at continued  pressure had to
be abandoned  on account of such  severe  symptoms  as were  here
caused, namely, "abdominal pain,  vomiting and general distress,"
it might  be better to wait longer  before  renewing the  attempt at
reduction, in the meantime using the  hot vaginal douches and other
measures calculated to remove tenderness  and lessen the sensibility
of the parts.f
  Again, persons as anaemic  as patients with inversion usually  are,
are notoriously liable to septicaemia from slight causes.   Now in the
case reported by Dr. Duncan, the instrument, [judging from the descrip-
tion very similar to the one employed in the present case,] was left in
position  two days after the patient had felt the parts slip back, for
what reason it is difficult to conceive, and then  found " incarcerated
in  the  cervix"  and " removed with difficulty."  During this length of
time the  uterus could not have been washed out,  and whether there
were any systematic and efficient cleansing of the parts  during the
  * Dr. White, in the course of his articles, after referring to Barnes's criticism, says that his
repositor may be used, to apply coninued pressure where this is deemed desirable—but this
is not properly " White's method."  Indeed he statestthat in every case he has operated, he
has replaced the  organ at one sitting.
  f Dr. Watts, of New York, has reported in the American Journal of Obstetrics, 1879, p. 16,
a case where reposition was successfully accomplished after three  months use of the hot
vaginal douche, several attempts before this having failed to replace the organ. 
9
 treatment does not appear in the report.  During two days, therefore,
 if not longer, the  patient must have been  exposed to the risks of
 septic absorption.   Further, the report states that, after removal of
 the instrument, " a purulent discharge from the uterus " was abundant
 at first, and very slight when she left the  hospital; that  the evening
 of the day the instrument was removed (the 9th inst.)  the  "patient
 sweated profusely"; that for  several  days "she had  much  bilious
 disorder and  occasional sickness, and vomiting"; that on  the  18th
 inst.  she " still had attacks  of sickness," and that during her fatal ill-
 ness  after leaving the hospital, she " suffered from anorexia  and  con-
 stant vomiting."   From these data it seems not improbable that sep-
 ticaemia may have had  something to  do  with the fatal  issue.  The
 nausea and vomiting, noted in  some other cases may  possibly  have
 been  due in a measure  to this same cause.  Be  that as it may, it will
 be well to employ in all cases frequent and thorough cleansings of
 the parts during the treatment, that this danger may be reduced  to a
 minimum.
   In  the obstetrical Transactions for 1878, xx. p. 126., Dr. Aveling
 describes and figures a " repositor " of his own  invention which  pos-
 sesses certain advantages.   Appreciating the fact that the  direction
 of the employed force is that of a straight line  drawn  from the ex-
 ternal end of the repositor where the force  is applied, to the other
 end which presses against the inverted organ, he has  given his vaginal
 stem, which is made of metal, a double  curve—the upper curve being
 that of the axis of the vagina, while a lower curve extends backward
 around the perineum and between the thighs.   This latter being made
 of greater or  less  length as the case may  require, the operator is en-
 nabled to direct his  pressure more  precisely than can be done where
 a straight stem is employed.  In some cases this will prove of advan-
 tage,  but probably in most cases the  simple straight stem will suffice
 and can, as in our case, be improvised for the occassion.
   Dr. Aveling, in the British Medical Journal of Sept. 6, 1879, gives
 several cases treated by continued  moderate pressure with success,
 and after  noticing the  methods  of treatment by incisions, sutures,
 dilatations, &c, expresses the enthusiastic opinion that "all these aids
 to reposition, whether they be harmless or dangerous, will henceforth
 be unnecessary."
  The devices (double india-rubber bags, etc.)which have been invented
 to compress the inverted body  and  thus render it  smaller and more
 easily replaced, are more ingenious than  useful, and practically  are
 of little value.
   Dr. Barnes recommends that when  a vaginal stem and elastic pres-
 sure are used, which was the method employed in our case, "counter-
 pressure should be exerted by pads  applied to the abdomen supported
 by a firm binder."
   I believe this counter pressure to be quite unnecessaiy.   Indeed
it would,  by  keeping  the   whole  uterus low  down  in  the  pelvis,
tend to prevent the longitudinal stretching  of the vaginal walls, by
which their action  in pulling upon the cervix uteri is brought  about. 
10
He also writes, " once a day, or every other day, the instrument may
be removed, and under chloroform an attempt at reduction  by taxis
may be made "; and the advice  has  been followed in many  of the
cases.
  I  consider  this employment of taxis thoroughly inadvisable un-
less  special indications arise in  the  given case.   It  is unnecessary
—must add both  to the mental and physical suffering of  the patient,
and  moreover robs the method of one of its greatest advantages, its
simplicity.
  It is rather remarkable, in view  of what is now  known  of the
subject, that the French writers still speak highly of amputation of the
inverted organ.  In an  essay by M. Hue, published this year  in the
Bull. Societe  de Chirurgie de Paris, the author expresses the opinion
that in cases of complete inversion the operator will be obliged - often
if not always," to have recourse  to amputation of the organ !  The
writer reports a  case  of amputation of an inverted  uterus by the
elastic legature, after taxis and the  vaginal bag  had been  tried, and
M. Chauvel in the same journal reports  a  similar case.   M. Forget,
at the meeting of  the Society July 9th, 1879, in presenting the models
of a case of complete inversion of the womb  found in a patient who
died in 1838, in the wards of Lisfranc, said he " did not  hesitate to
affirm that  in a case of complete inversion of 15 months duration, re-
duction would be  impossible," and that he would  in such  a case, if
interference became necessary, remove the organ " by  the  use  of the
elastic ligature and cauterization with chloride of zinc, after the plan
recommended by  M. Valette." !  Regarding amputation, Dr. Barnes
writes—" It is a confession of impotency to solve  the problem  of re-
duction.  It is the last recourse, one  to which I  am fully convinced,
we need hardly ever, if ever, be  driven.   Prof.  White, whose wide
experience with such cases gives weight to his words, thus expresses
his opinion: " I am incredulous as  to the necessity of  ever resorting
to amputation."   We  can only hope that it may soon become an
operation of the past.
  In the British Medical Journal of Sept. 6, 1879, Dr. Barnes re-
ports a case  where  he amputated an inverted uterus with the ecra-
zeur, having  begun the operation  under the impression that he was
dealing with a polypus.  The  woman had passed the  change of life
(being 49  years of age), and  had had a polypus removed some two
years  before.  Dr. Barnes, in his  remarks upon  the case, distin-
guishes cases  of chronic  inversion met  with in  patients  who have
passed the  climacteric,  which cases  he terms "senile chronic,"  from
those chronic cases which occur before the menopause—holding that
in the.former cases, while amputation is less  open  to  objection, re-
duction is much more difficult of execution.
  It is well to remember that  somewhat similar  reasoning leads the
French writers to prefer amputation to reduction in  cases of common
chronic inversion, and it  would seem best to reserve amputation for
those cases where  attempts at reposition, made according to  the best
methods, have failed, and the need  of interferance is  pressing; for 
11
as Dr. Barnes truly says, "It must be borne in mind that, especially
in the senile chronic inversions, tolerance may be acquired, and thus
render all operative interferance unnecessary."
   Dr. Thomas, of New York, in his text book on The Diseases of
Women, while making a very cursory mention of " gradual reduction
by repositor " in a paragraph of  less than nine lines, devotes more
than  nine pages to  a description of a plan of treatment suggested by
Sir  James  Simpson,  which he  has  twice  carried  out,  namely:
 He has opened  the abdominal cavity,  thus getting at the  inverted
organ from the peritoneal side;  has dilated rapidly  with  an instru-
ment fashioned  like  a glove-stretcher  the constriction  which  was
the impediment to  reposition, and  then  replaced by taxis by the
vagina.  The first patient upon whom the method  was tried  recover-
ed ;  the second one died.   The procedure has not  met with much
favor, and I am  not aware of its having been resorted to by any one
else.   White  speaks of it as "still more objectionable"  than ampu-
tation.  Barnes's opinion is that "a method which requires gastro-
tomy for its execution involves conditions  of danger  so great  that
even  amputation seems preferable," and  Emmet looks  upon it as
more  dangerous than  ovariotomy.   A review of the two cases is
rather interesting in this connection.
   The first patient was a  delicate woman, twenty-three years  old,
and  the inversion was of twenty-three months' standing.   Taxis had
already  been   thoroughly  tried  ten  different  times, each  time
the  patient being  anaesthetized, and  each  time the  effort being
systematically followed by the use of the vaginal bag distended with
air.    Dr. Thomas, after giving the patient the warm vaginal douche
and belladonna  suppositories, tried taxis in various ways—four more
times, varying the treatment by following  up  the  attempts  at taxis
with  the vaginal bag distended with water in place of air.  He states
that  he  would  have resorted  to  Emmets method  of temporarily
closing the cervix with sutures  below the  inversion, but the fundus
was never got sufficiently high to admit of it.   Having no  success
with  taxis, he thought of passing " a delicate tenotome through the
fundus, carrying it  up through the  cervical canal and incising its  four
sides so as to cut through the constriction existing there and due to
fibres near the os internum."   This idea  was not carried out, and I
think we may say it was fortunate, for as  more or less of the Fallo-
pian tubes and the  broad ligaments are carried along with the inver-
sion,  there is no telling what might have been cut in the procedure.
He next resorted to an operation which has been done in a few cases
successfully.   Drawing down the inverted organ, he made an incision
at the point of constriction through the  mucous membrane, and " ex-
tending down toward the subjacent peritoneum," in hopes that after
being thus incised the constriction would  yield to  taxis;  but the in-
cision was immediately followed by severe bleeding, " upwards of a
dozen " ligatures  were used, but the vessel having retracted could
not be tied.   Finally, Dr. Nott, who was  present, checked  the  flow
by sewing the surfaces of the incision together.   Some sloughing of 
12
the mucous membrane followed.  After the patient was in a fit state
again, Dr. Thomas proceeded to open the abdomen  and dilate  the
constriction after the method described above.   On applying taxis
after this had been done, the bleeding which had been so troublesome
before began afresh.   Seeing that  he had no time to waste, he re-
turned the organ rapidly, but  in so doing forced his finger through
the  vagina, between  the  bladder  and  the  uterus.   The  next day,
bleeding, probably from the same source as before, was severe—blood
flowing freely from the vagina, and also " through the  vaginal  rent
into the peritoneum."  The patient's pulse ran up to  160, and the
symptoms were so serious  that preparations for transfusion were
made.   However,  the  bleeding ceased  on raising  the foot of  the
bed, and using tannin in the vagina.   The patient fortunately escaped
peritonitis, and subsequently got  well.   This  was the successful
case.
   The other case was one of eight months' standing.   " Ordinary
means, elastic pressure and taxis," had been "exhausted without avail."
From the restricted  sense, previously  referred  to, in which  the
author uses  the term  " elastic pressure," it is to  be presumed  that
the "elastic pressure " which had been exhausted was again the " vagi-
nal bag."   The operation was done, as in the first case, but without
the complication of haemorrhage, and without rupturing the  vagina.
At the  end  of 48  hours  peritonitis  developed, and the case ended
fatally.
   I would particularly  ask  attention to the fact, that  Dr. Thomas
writes regarding the first case that  he  "found  no adhesion what-
ever to exist," and  that  when he  inserted his  dilator and dilated
the stricture, " the dilatation was exceedingly easy and  rapid."   Of
the second, the fatal case, he writes, " introducing one finger into the
sac  of  the inverted uterus, I inserted the dilator, and in  sixteen
minutes withdrew it, and, with an ease  which  surprised  us all, re-
placed the uterus."   Referring to the treatment this last patient had
had before he saw her, and  the previous attempts at reduction, he
says that the last effort (at reduction) was a " very persistent one "
which lasted  for  " two hours."    In our case  it was not until the
evening of the  second day, when pressure had been  continued  more
than 30 hours that  any gain  could be appreciated, yet  the final
result was all that could be  wished  for.
   While it would be foolish to suppose that in every case where sus-
tained moderate pressure is tried the result will be as easily successful
as it proved in  our case, or that any  one method  of treatment will
invariably suffice, still on  reviewing these  two  cases I cannot  but
think that we may with full justice  exercise the Yankee prerogative,
and guess  that  if the easy, simple, safe and, in view  of physiological
knowledge, common sense method of treatment by continued moderate
pressure properly applied had  been tried, these truly  heroic oper-
ations, which by their boldness excited marked attention in medical
circles both at home and abroad, would never have been performed. 
 
Tr